The author considers that a large group of clinical phenomena, of which perversion is the most dramatic example, is characterised by the effort to disavow troubling perceptions of reality. In these cases, patients are sometimes characterised—erroneously, in his view—as living in a different ‘psychic reality’. He suggests that patients who use perverse defences are able to distinguish fantasy from reality, but they are motivated to refrain from testing cherished fantasies against their own view of reality. Such patients are difficult to work with, because they dismiss painful realities in treatment as readily as any other unwanted perceptions. The author suggests that treatment must focus on the various disavowals of the patient's own perceptions of reality, to the extent that the analyst must be prepared to be a spokesperson for reality. Treatment in which the patient's ‘psychic reality’ is viewed as a ‘kind’ of reality rather than addressed as a fantasy can thus collude with perverse defences.